Failure to Monitor PICC Line Care and Significant Weight Gain per Practitioner Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its infusion therapy policy and practitioner orders for a resident with a PICC line and daily weight monitoring. The facility’s policy for infusion therapy required that for a PICC line, the patient’s upper arm circumference be measured on insertion, on admission, and when clinically indicated, and that the external catheter length be measured on admission and weekly to monitor for outward migration. Record review for one resident showed an order for a PICC line dressing change every seven days while on IV antibiotics, but there were no corresponding orders to change the PICC line caps or to measure the external catheter length. The Wound and Infection Nurse confirmed that the resident did not have orders for PICC line cap changes or weekly external length measurements and that such orders should have been in place. The deficiency also includes the facility’s failure to monitor and evaluate significant weight changes according to practitioner orders. The resident’s MDS indicated the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had two venous ulcers. The practitioner’s order required daily weights and notification of the provider if the resident gained more than 3 to 5 pounds in a week. The EHR showed the resident’s weight increased from 133.9 lbs on one day to 152 lbs the next day, an 18.1 lb gain. The ADON confirmed that staff did not monitor this weight change and did not notify the provider of the significant weight gain, despite the existing order to do so.
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